Methods for generating healthcare provider quality and cost rating data

ABSTRACT

A method for generating healthcare provider quality rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, assessing the claim records in each claim group using guidelines for the particular disease or condition, and generating a compliance score for the claim group, wherein the compliance score indicates the extent to which the claim records in the claim group match the guidelines, and generating normalized provider quality rating data. A method for generating healthcare provider cost rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, calculating the total cost of each claim group, aggregating the total cost for each claim group, and comparing the total aggregate cost of each claim group assigned to each provider to an expected cost value.

FIELD OF THE INVENTION

The present invention relates to methods for generating provider qualityratings and cost ratings that may be used, for example, in a consumerhealthcare guide, to provide consumers with information to makebetter-informed healthcare choices.

BACKGROUND

The selection of healthcare services, products and providers may bedifficult for consumers for a number of reasons. Often, meaningfulhealthcare information is unavailable to consumers. For example,health-related costs to the consumer in any given market for any givenprocedure may vary, and the consumer may not have access to the currentcosts they may incur for receiving a health-related service or product.In addition, the quality of care may vary within any given market. Forexample, various providers may have differing levels of experience orskill for a given procedure, product or service, but this informationtypically is not available to consumers. As a result, consumers oftenmake choices concerning their healthcare products, service and/orproviders without the benefit of accurate cost and quality information.

SUMMARY

The present invention provides methods for generating provider qualityratings and cost ratings that may be utilized, for example, in aconsumer healthcare guide to provide consumers with information to makebetter-informed healthcare choices or for analysis purposes, such as toresearch correlations between provider cost and quality ratings. Theprovider quality and cost rating data also or alternatively may bestored and analyzed for various purposes, for example, to investigatecorrelations between provider quality and cost ratings. Providers forwhom quality and cost rating data are generated may include doctors andother providers of health-related services, as well as facilitiesincluding hospitals, clinics and other facilities at whichhealth-related services are provided.

Provider quality and cost rating data generated by the consumerhealthcare guide may be generated by utilizing a database of medicalclaim data collected for each provider to be assessed or rated.

A method for generating healthcare provider quality rating data mayinclude: receiving a plurality of claim records representing servicesprovided by a plurality of healthcare providers to one or more patients;grouping the claim records into at least one claim group, such as anepisode of care, wherein each episode of care comprises claim recordsthat relate to treatment of a patient for a particular disease orcondition; assigning each claim group to a responsible provider;assessing the claim records in each claim group using guidelines for theparticular disease or condition associated with the claim group andgenerating a compliance score for the episode, wherein the compliancescore indicates the extent to which the claim records in the episode orclaim group match the guidelines; aggregating the compliance score forall claim groups assigned to each respective provider to generate a rawaggregate compliance score for each provider; normalizing the provider'sraw aggregate compliance score to a defined scale to generate anormalized aggregate compliance score for each provider; and generatingprovider quality rating data for each provider using the normalizedaggregate compliance score. Quality rating data may be generated formultiple providers by aggregating the scores for each episode of care orclaim group assigned to each provider to obtain a quality rating (eitheroverall including all conditions treated or by condition) for eachprovider using the above-described method. The guidelines may beevidence based medicine guidelines. The aggregate raw compliance score,the normalized aggregate compliance score, and the provider qualityrating data may be calculated separately for each condition or diseasetreated by the provider and/or calculated to include all conditions anddiseases treated by the provider. The raw aggregate compliance scoreoptionally may be normalized using average aggregate compliance valuesfor a defined geographical region in which the provider is located. Theprovider quality rating data optionally may comprise one or moreperformance categories or graphic symbols (such as stars or a gaugesimilar to a thermometer) that indicate the provider's quality oftreatment in comparison to an average value.

A method for generating healthcare provider cost rating data mayinclude: receiving a plurality of claim records representing servicesprovided by a healthcare provider to one or more patients; grouping theclaim records into at least one claim group, such as an episode of care,wherein each episode of care comprises claim records that relate totreatment of a patient for a particular disease or condition; assigningepisodes of care or claim groups to responsible providers; calculatingthe total cost of each episode of care of claim group, wherein the totalcost is the sum of the costs associated with each claim record in theepisode of care or claim group; aggregating the total cost for allepisodes of care or claim groups assigned to each respective provider toobtain a raw aggregate cost score for each provider; comparing the totalaggregate cost of each episode of care or claim group to an expectedcost value; normalizing each provider's raw aggregate cost score to adefined scale to generate a normalized aggregate cost score for eachprovider; and generating provider cost rating data for each providerusing the normalized aggregate cost score. Cost rating data may begenerated for multiple providers by aggregating the scores for eachclaim group assigned to each provider to obtain a cost rating (eitheroverall including all conditions treated or by condition) for eachprovider using the above-described method. The expected cost value foran episode of care or claim group may be an average risk-adjusted costvalue calculated from historical cost data. The aggregate raw costscore, the normalized aggregate cost score, and the provider cost ratingdata may be calculated separately for each condition or disease treatedby the provider and/or calculated to include all conditions and diseasestreated by the provider. The raw aggregate cost score optionally may benormalized using average aggregate cost values for a definedgeographical region in which the provider is located. The provider costrating data may comprise one or more performance categories or graphicsymbols, such as gauges, that indicate the provider's cost of treatmentin comparison to an average value.

The provider quality and/or cost rating data generated by the abovedescribed methods may be utilized in a consumer healthcare that enablesconsumers to access quality and/or cost rating information concerninghealthcare providers (including healthcare practitioners, such asphysicians, and/or healthcare facilities, such as hospitals). The guidemay provide consumers with increased transparency in relative cost andquality in the healthcare marketplace, which enables the consumer tomake better-informed healthcare decisions.

In implementations in which both cost data and quality data areprovided, the guide may enable consumers to weigh cost and qualityinformation in selecting a provider to identify the best quality levelat their desired cost level. The consumer healthcare guide may be, forexample, a web-based provider lookup tool that provides cost and/orquality data relating to providers such as physicians or hospitals.

Additionally, provider volume data, including such information as thenumber of procedures (overall and/or specific procedures) performed byeach provider, patient age ranges, patient gender information (such asnumber or percentage of male and female patients), and/or top conditionstreated or procedures performed by each provider, may be provided by theguide.

Additionally or alternatively, the quality and/or cost rating datagenerated by the methods described herein may be utilized for dataanalysis, for example, to research correlations between cost and qualityfor health care providers or to assess the performance of providersbased upon their relative quality and cost ratings (for example, toidentify providers who provide high quality care at low to averagecost).

These and other features and advantages of the present invention willbecome apparent to those skilled in the art from the following detaileddescription, wherein it is shown and described illustrativeimplementations of the invention, including best modes contemplated forcarrying out the invention. As it will be realized, the invention iscapable of modifications in various obvious aspects, all withoutdeparting from the spirit and scope of the present invention.Accordingly, the drawings and detailed description are to be regarded asillustrative in nature and not restrictive.

DESCRIPTION OF THE DRAWINGS

FIG. 1A is a flowchart of a method for generating healthcare providerquality rating data that may be utilized, for example, in the system andmethod of FIGS. 1C and 1D.

FIG. 1B is a flowchart of a method for generating healthcare providercost rating data that may be utilized, for example, by the system andmethod of FIGS. 1B and 1D.

FIG. 1C is a diagram of an exemplary system for providing a consumerhealthcare guide that enables consumers to access provider qualityand/or cost rating data generated by the methods of FIGS. 1A and/or 1B.

FIG. 1D is a flowchart of a method for providing the consumer healthcareguide of FIG. 1C.

FIGS. 2-16 depict illustrative displays of rating data, such asgenerated using the methods of FIGS. 1A and 1B, which may be accessedand utilized by the system and method of FIGS. 1C and 1D.

DETAILED DESCRIPTION

Methods for generating health care provider quality rating data and costrating data that may be utilized, for example, in a consumer healthcareguide or to research correlations between cost and quality for healthcare providers are described below with reference to the accompanyingdrawings.

Providers for whom quality and/or cost rating data are generated mayinclude doctors and other providers of health-related services, as wellas facilities including hospitals, clinics and other facilities at whichhealth-related services are provided.

With reference to FIG. 1A, a method for generating healthcare providerquality rating data begins with the receipt (150) of claim data, forexample, previously adjudicated claim data associated with a pluralityof healthcare providers and a plurality of patients, such as health planmembers, for a defined period of time.

Next, the claim data is grouped into units or groupings that can beattributed to a specific healthcare provider (e.g., physician orhospital). Any desired grouping methodology may be implemented.

For example, claim data may be grouped into episodes of care (151),wherein an episode can be defined as a group of related servicesrendered to a patient to manage a disease condition. An episode may takeinto account all services provided for a disease condition during apre-defined period of time and may include office visits, outpatientcare, inpatient care, surgeries, laboratory services, radiology,pharmacy, and other related services.

One method of grouping claims into episodes of care using episodetreatment groups is described in U.S. Pat. No. 5,835,897, entitled“Computer-Implemented Method for Profiling Medical Claims,” and isincorporated herein by reference. Additionally or alternatively, theclaim data may be grouped into episodes of case using a groupingmethodology such as that disclosed in U.S. patent application Ser. No.11/369,198, filed Mar. 6, 2006, entitled “Claims Analysis Tools andMethod,” incorporated herein by reference, in which claims are groupedusing anchor and target procedure groups, or U.S. Pat. application Ser.No. 11/759,616, filed Jun. 7, 2007, now issued as U.S. Pat. No.7,801,749 on Sep. 21, 2010, entitled “System and Method for GroupingClaims Associated with a Procedure,” incorporated herein by reference,in which claims may be grouped using procedure episode groups.

Alternatively, claims may be grouped using an APR-DRG grouper, such asthat designed by 3M® Corporation, which assigns a base class to eachmedical claim based upon the DRG and primary diagnosis codes. Thegrouper further may assign a severity of illness (SOI) class 1-4depending on the secondary diagnosis codes and other membercharacteristics in the claims. The grouper additionally may assign arisk of mortality (ROM) class 1-4 based on the member's risk of dying asinferred from secondary diagnosis codes and demographic information ofthe member. This grouper may be implemented, to group facility claimsattributable to certain healthcare facilities, such as hospitals, toenable computation of quality and/or cost rating data for suchfacilities in comparison to expected or average values for such facilityquality and costs.

The grouping methodology selected to implement 151 above may be selectedto group claims in such a way as to enable accurate attribution orassignment of each episode to a specific healthcare provider (asperformed in 152, discussed below). Since providers are evaluated basedupon the claim groups attributed or assigned to them, claims should begrouped into episodes of care or other groupings that accuratelyrepresent the services rendered by the provider to whom each episode ofcare is assigned. Accordingly, one or more grouping methodologies may beimplemented for this purpose.

For example, the procedure episode grouper described in U.S. Pat. Ser.No. 7/801,749 (referenced above) may be implemented to group processclaim data into specific and discrete procedures, for example, relatedto one of a plurality of cardiac or musculoskeletal procedures. Examplesmay include heart transplants, spinal fusions, and hip replacements.Using the procedure episode grouper in conjunction with an episodegrouper, specific resource-intensive procedural costs and services canbe carved out of the episodes of care into procedure episode groups,leaving the episodes of care to include the medical episodes and theirrelated costs and services. Thus, discrete procedures, such assurgeries, that are performed by a procedure provider, such as asurgeon, are separated from medical episodes, which include servicesthat may be medically related to the surgery but are provided by adifferent (e.g., non-surgical) provider.

After the claims are grouped as described above, each episode of care orother grouping is analyzed to identify the provider to which the episodeis to be attributed or assigned (152). For example, episodes of care maybe assigned to providers based upon their degree of involvement in thecare for an episode. Thus, performance of the provider may be measuredfor the treatment provided for the entire continuum of care for acertain disease condition.

In one implementation, an episode of care is attributed to one or moreproviders using the following rules:

-   -   An episode is attributed to all providers responsible for more        than 25% of non-facility costs of the episode;    -   An episode is attributed to all providers associated with a        management or surgery record if the provider is responsible for        more than 25% of the services within the episode.    -   Episodes are attributed to all providers meeting either of the        above two criteria.

In this example, an episode is attributed to providers if they areresponsible for more than 25% of the services or costs of the episode.In this manner, episodes are assigned to providers based upon theirinvolvement in the care for an episode.

Notably, if the claim data received in 150 relates only to one provider,function 152 may be omitted, as all episodes within the received claimdata are attributable to the same provider and the assignment processmay be unnecessary.

Additionally, the risk associated with each episode optionally may beassessed, for example, by identifying co-morbidities of a patient, inorder to generate a risk profile for the patient. The risk profile mayinclude both past and future risk scores for each patient. Eachpatient's risk score may be used to generate a severity metric forassociated providers. A provider's severity metric may be based, forexample, on the risk scores for all episodes of all patients treated bythe provider, and may be aggregated for the provider and/or assessed ona condition-by-condition basis (e.g., including only episodes associatedwith one or more specific conditions or diseases).

Once each episode has been assigned to one or more providers, eachepisode of care is assessed to determine whether the episode of carecomplies with expected treatment for the disease or condition (153). Inone implementation, this is accomplished by using evidence basedmedicine (EBM), wherein the episodes of care are assessed forconsistency with widely accepted guidelines for treatment, for example,using a software application such as EBM Connect™ offered by IngenixCorp., of Eden Prairie, Minn. The software may indicate under-use ormisuse of services based on a series of measures such as those relatedto disease management, medication adherence and compliance, patientsafety, or care patterns.

For example, the following rules may be used for the condition ofcongestive heart failure:

Rule Requires Type Description of Clinical Measure Action DiseaseManagement R-1 Patients currently taking an ACE-inhibitor or acceptablealternative. X R-1 Patients currently taking a beta blocker. R-2Patients currently taking spironolactone. Medication Adherence APatients compliant with prescribed ACE-inhibitor or acceptablealternative. A Patients compliant with prescribed beta blocker. X APatients compliant with prescribed spironolactone. X A Patientscompliant with prescribed digoxin. Patient Safety S-M Patients takingmedication that had serum potassium (K+) test. S-M Patients takingmedication that had serum creatinine (Cr) test. S-M Patients currentlytaking digoxin that had a serum digoxin test in the last 24 months. S-MPatients currently taking digoxin that had serum creatinine (Cr) test.S-M Patients currently taking digoxin that had serum potassium (K⁺)test. S-DI Patients currently taking contraindicated medication. S-DIPatients currently taking contraindicated medication. X Care PatternsCP-C Patients with more than one echocardiogram in the past year(excluding patients with a X diagnosis of unstable angina or patientsadmitted for an AMI). CP-I Patients with an annual physician assessment.CP-I Patients with indications that had a Cardiology consultation.

The software application may identify patients with selected clinicalconditions and evaluate particular aspects of their care by applyingclinical rules to identify whether treatments did or did not occur(referred to as gaps in care).

Dr. Jones Patients being treated for the condition of: Asthma ResultDate last Mary Smith Age 50 Gender F Flag Relevant Service Patients withpresumed persistent asthma using an inhaled corticosteroid Y Apr. 9,2003 Patient using inhaled long-acting beta2-agonist also using inhaledN Apr. 9, 2003 corticosteroid in past 3 months Patient on leukotrienemodifier >90 days w/possession ratio >70% in past Y Dec. 29, 2003 6months Patient on theophylline >90 days w/possession ratio >70% in past6 N/A N/R months Patients on theophylline had an annual serumtheophylline level. N/A N/R Patient on zyflo medication had serum ALT orAST in the past year N/A N/R Patient had an office visit for asthma inpast 6 months Y Aug. 6, 2003 Patients frequently using short-actingbeta2-agonist inhalers that had an N Aug. 6, 2003 office visit in thepast 3 months. Patient exhibiting poor control of asthma seen byallergist or pulmonologist N N/R in past year Patients that had a PFT NN/R

All of the applicable rules for a physician's patients may be aggregatedas follows to generate a compliance score for the provider (154):

Dr Jones Congestive Heart Failure (CHF) Number of Patients = 10 RuleCompliance Type Description of Clinical Measure Compliant Eligible RateR-1 Patients currently taking an ACE-inhibitor or 8 10 80% acceptablealternative. R-1 Patients currently taking a beta blocker. 6 10 60% R-2Patients currently taking spironolactone. 4 10 40% A Patients compliantwith prescribed ACE-inhibitor or 7 8 88% acceptable alternative. APatients compliant with prescribed beta blocker. 6 6 100% A Patientscompliant with prescribed spironolactone. 3 4 75% A Patients compliantwith prescribed digoxin. 2 3 67% S-M Patients taking medication that hadserum potassium 6 9 67% (K+) test. S-M Patients taking medication thathad serum creatinine 6 9 67% (Cr) test. S-M Patients currently takingdigoxin that had a serum 2 3 67% digoxin test in the last 24 months. S-MPatients currently taking digoxin that had serum 3 3 100% creatinine(Cr) test. S-M Patients currently taking digoxin that had serum 3 3 100%potassium (K⁺) test. S-DI Patients currently taking contraindicatedmedication. 1 10 10% S-DI Patients currently taking contraindicatedmedication. 1 10 10% CP-C Patients with more than one echocardiogram inthe 4 8 50% past year (excluding patients with a diagnosis of unstableangina or patients admitted for an AMI). CP-I Patients with an annualphysician assessment. 8 10 80% CP-I Patients with indications that had aCardiology 2 2 100% consultation.

A comprehensive EBM score may be generated for each physician afterweighing each rule by its relative importance. An exemplary table of EBMrule weighting is as follows:

Report Rule Weight Condition Id RuleDescription 2 Congestive HeartFailure 9136001 Patient(s) currently taking an ACE-inhibitor oracceptable alternative. 2 Congestive Heart Failure 9136002 Patient(s)currently taking a beta-blocker. 0 Congestive Heart Failure 9136003Patient(s) currently taking spironolactone. 0 Congestive Heart Failure9137004 Patient(s) compliant with prescribed ACE-inhibitor or acceptablealt. 0 Congestive Heart Failure 9137005 Patient(s) compliant withprescribed beta-blocker. 0 Congestive Heart Failure 9137006 Patient(s)compliant with prescribed spironolactone. 0 Congestive Heart Failure9137007 Patient(s) compliant with prescribed digoxin. 2 Congestive HeartFailure 9138008 Patient(s) taking ACE-inhibitors, angiotensin receptorblockers or spironolactone. 2 Congestive Heart Failure 9138009Patient(s) taking ACE-inhibitors, angiotensin receptor blockers orspironolactone. 2 Congestive Heart Failure 9138010 Patient(s) takingdigoxin that had a serum digoxin test in last 24 reported months. 2Congestive Heart Failure 9138011 Patient(s) taking digoxin that had aserum potassium test in last 12 reported months. 2 Congestive HeartFailure 9138012 Patient(s) taking digoxin that had a serum creatininetest in last 12 reported months. 1 Congestive Heart Failure 9138013Patient(s) taking contraindicated NSAID medication. 2 Congestive HeartFailure 9138014 Patient(s) taking contraindicated Class Ianti-arrhythmic medication. 1 Congestive Heart Failure 9139015Patient(s) with more than 1 echocardiogram in last reported 12 months. 2Congestive Heart Failure 9139016 Patient(s) having an annual physicalassessment. 2 Congestive Heart Failure 9139017 Patient(s) withindications that had a cardiology consult in last 24 reported months.

The EBM software may rate providers on their adherence to guidelines andprovide an EBM score that can be compared directly with EBM scores ofother providers, and/or with state averages. The EBM score may furtherbe used to generate provider quality rating data, as discussed below indetail.

In particular, the compliance scores for each episode of care may beaggregated on the provider level (155) and also on the condition levelfor each provider (156). In other words, an aggregate provider score maybe calculated as the average of all compliance scores for the episodesassigned to the provider, regardless of condition. Compliance scoresaggregated at the condition level may be calculated as the average ofall compliance scores received by the provider for episodes associatedwith a specific condition. Compliance scores may be risk adjusted, forexample using patients' risk profiles, so that each provider'scompliance sores are compared to those of peers treating similarepisodic conditions.

Based upon the aggregate compliance scores, a raw quality score may becalculated (157) for a provider, both overall and by condition. The rawquality score may be the EBM compliance score, or may be a weighted sumof the EBM compliance score and other factors or utilization measures,which may be risk adjusted, for example, using the patient's riskprofile discussed above. Alternatively, if there is no EBM score, forexample, when there are no EBM criteria with which to assess a givenepisode of care, other utilization measures may be assessed and weightedto generate a raw quality score.

For example, in one implementation, the raw quality score is calculatedas the weighted sum of a provider's EBM compliance score, and threeutilization measures: risk-adjusted inpatient days per year (I),risk-adjusted emergency room visits per year (E), and risk-adjustedoutlier cost (O) (for example, representing the number of potentiallyavoidable procedures) as follows:Raw quality score=0.7 (EBM compliance score)+0.1(I)+0.1(E)+0.1(O)

If there is no EBM score for a given episode of care, a raw qualityscore for the episode may be generated by providing a weighted sum ofthe I, E, and O utilization measures.

In an alternative implementation that may be utilized, for example, whenthe provider is a facility such as a hospital and no EBM score isobtained, the raw quality score may be calculated as the weighted sum offour utilization measures obtained using in-patient and/or out-patientfacility claims attributed to the provider: death rate (D), complicationrate (C), length of stay (L), and risk-adjusted avoidable days (A) (forexample, representing the number of potentially avoidable days) asfollows:Raw quality score=0.35(D)+0.3(C)+0.2(L)+0.15(A)

Once calculated, for example, using one of the formulae described above,the raw quality score then may be adjusted and normalized (158). Forexample, the raw score may be adjusted based upon the average orexpected value based on specialty, presence of pharmacy claims,geographical location, and/or type of disease or condition. The adjustedscore may then be normalized, for example, to a scale of 0-100. Thenormalized score may then be used to generate quality rating data forthe provider (159), either overall, by condition, or both.

For example, if a normalized scale of 0-100 is used, provider qualityrating data may be generated according to the following rules:

Score Rating >95 Significantly above average 75-94 Above average 25-74Average <25 Below averageIn this example, quality rating data includes an assigned performancecategory that indicates each provider's quality of treatment incomparison to other providers.

Alternatively, provider quality rating data may be generated accordingto the following rules:

Score Rating  95-100 ***** 75-94 **** 50-74 *** 25-49 **  0-24 *In this example, quality rating data includes an assigned graphicrepresentation that indicates each provider's quality of treatment incomparison to other providers.

Alternatively, any desired rating categories, scores and definitions maybe implemented.

The provider quality rating data as well as the underlying EBMcompliance score and other factors utilized in the method describedabove with reference to 150-159 may be stored (160) for access by usersof a consumer guide (described below with reference to FIGS. 1C and 1D),health plan administrators, data analysts, and other desired users.

Norms that may be utilized, for example, for developing expected values,for risk adjustment and/or for standardizing risk-adjusted values, maybe developed as follows with reference to episodes of care andassociated episode treatment groups (ETGs), which are categories thatmay be utilized to group claim records into episodes of care.

Episodes are assigned to providers, such as physicians, based upon theirdegree of involvement in the care included in the episode (as discussedabove). Average performance of physicians may then be calculated foreach measure for each geographical region (e.g., state) using theinformation from all similar types of physicians in the region treatingsimilar conditions after adjusting for outliers. For example, theperformance of a primary care physician (PCP) may be compared with thatof an average PCP, and a PCP treating diabetes may be compared with anaverage PCP treating diabetes.

For example, average costs may be developed for each ETG, for eachphysician specialty, and based upon whether the physician has associatedpharmacy benefits as follows:

Pharm Episode Count ETG Specialty Description Ind (Aftr Outlrs) Avg Cost0027 INTERNIST N 413 887.03 0027 INTERNIST Y 357 2,319.77 0027FAM/GEN/PRIM CARE N 386 866.68 0027 FAM/GEN/PRIM CARE Y 343 1,882.820027 ENDOCRINOLOGIST N 234 782.95 0027 ENDOCRINOLOGIST Y 230 2,645.490027 EMERGENCY MEDICINE N 65 2,025.22 0027 EMERGENCY MEDICINE Y 334,895.07 0027 CARDIOLOGIST N 31 1,780.37 0027 CARDIOLOGIST Y 17 3,384.510027 NEPHROLOGIST N 14 4,744.79 0027 NEPHROLOGIST Y 29 7,789.86

Average values calculated using the normative database are used todevelop expected values for each performance metric for physicians andfor the purposes of risk adjustment, based upon physician specialtytype, mix of episodes, and pharmacy benefits.

With reference to FIG. 1B, a method for generating provider cost ratingdata follows the functionality described with reference to 150-152 ofFIG. 1A. As with the method of FIG. 1A, if the claim data received in150 relates only to one provider, function 152 may be omitted, as allepisodes or claim groups within the received claim data are attributableto the same provider such that the assignment function may not benecessary. After episodes or claim groups have been assigned to aprovider (152), the cost of each episode or claim group is calculated(161). The cost may be the total allowed claim amounts for the entireepisode of care of claim group. This may include the health plan'sreimbursement along with the patient's portion, including co-paymentsand deductibles. Costs may be aggregated by all provider episodes andseparately for each condition treated. Costs may be risk adjusted, forexample using patients' risk profiles, to account for higher costs insicker patients. Risk adjusted costs may be compared to those of peerstreating similar episodic conditions.

The costs are then aggregated by provider (162) and/or condition (163)to determine each provider's observed costs for all treatments renderedby the provider and/or each condition or disease treated by theprovider. Each provider's observed costs are then compared with expectedcosts for an average provider based on specialty, presence of pharmacyclaims, and geographical location (e.g., same state) to generate a rawcost score for the provider overall and/or for each condition treated bythe provider (164).

The raw costs score for each provider for each condition treated maythen be normalized (165) using the geographical (e.g., state) average tocalculate the risk-adjusted costs. Each provider's risk-adjusted costsare compared with average costs to generate cost rating data (166) foreach provider (for all conditions and/or on a condition-by-conditionbasis), for example using the same scale of 0-100 and ratings describedabove with reference to 159 in FIG. 1A. The cost rating data may bestored (167) and accessed by users of a consumer guide, health planadministrators, data analysts, and other desired users. In one examplein which both quality and cost rating data has been generated, thestored quality and cost data may be utilized to research and analyzecorrelations between provider cost and quality.

In one implementation, provider cost rating data may be generated asfollows. The expected value for provider costs may be the average costthat would result if the provider's mix of patients by severity levelhad been treated at the average cost in a reference normative database.An individual provider's expected costs may be derived using normstables depending on the specialty type for the various conditionstreated. For example, if an internist treats twenty-five episodes ofhypertension in the state of Kentucky (KY), the expected costs for thiscondition would be based on the distribution of episodes of high bloodpressure within the condition “hypertension.” These costs may be derivedfrom the norms tables for hypertension for Kentucky as shown below:

Internist Pharmacy Pharmacy M0507 High Blood Pressure, Hypertension NoYes 0278 Malignant hypertension, with $1,127   $1,343   comorbidity 0279Malignant hypertension, w/o $569 $862 comorbidity 0280 Benignhypertension, with comorbidity $597 $698 0281 Benign hypertension, w/ocomorbidity $375 $605Therefore, the internist's expected costs would be derived as follows:

Phar- macy Episode Volume Cost No Malignant hypertension, withcomorbidity 0    $0 Yes Malignant hypertension, with comorbidity 2$2,687 No Malignant hypertension, w/o comorbidity 1   $569 Yes Malignanthypertension, w/o comorbidity 3 $2,586 No Benign hypertension, withcomorbidity 5 $2,985 Yes Benign hypertension, with comorbidity 8 $5,583No Benign hypertension, w/o comorbidity 4 $1,501 Yes Benignhypertension, w/o comorbidity 2 $1,210 25  $17,120  Expected   $685Costs

This method allows for risk-adjustment by provider type, episode type,and presence or absence of pharmacy benefits. The provider's observedcosts for treating hypertension ($1,159 in the above example) arecompared with expected costs ($685 as calculated above) to create aperformance index that is normalized using the state average fortreating hypertension ($466 for KY) to calculate the risk-adjusted cost($789). A provider's risk-adjusted costs may be compared directly acrossall providers, who have been normalized against the same state average.

While the example given above is for a single condition, the computationmay be expanded to include multiple conditions or the entire practice ofthe provider. In the following example, risk-adjusted costs arecalculated for an internist in KY for each condition treated based uponexpected costs for the mix of patients within each condition derivedfrom the normative database. These values are compared with their statenorms, and ratings are calculated:

Risk- Condition Adjusted Code Condition Name Volume Cost Norms M0507High Blood Pressure, 25 $789 $466 Hypertension M0508 Hyperlipidemia 14$424 $436 M1001 Diabetes 11 $1,521   $1,069   M0808 Musculoskeletal 9$483 $289 Problems M1002 Goiter, Thyroid 8 $643 $402 Problems, ThyroidCancer M2501 Immunizations, 6 $263 $173 Preventive Services, Check-upsM0303 Acute sinusitis 5 $179 $189 M0903 Skin Infection, Cellulitis 5$162 $175 M1903 Minor Depression 5 $805 $502

As illustrated above, to compare the performance of providers, aseverity-adjusted value for each provider is computed and standardizedusing a geographic standard. Thus, for a given condition, thephysician's costs are computed after being adjusted for severity ofpatients treated, based on the mix of ETGs within the condition. Then,the risk-adjusted costs are compared against a constant reference value,which represents the average costs for the given condition in a givengeographical area. This comparison may be utilized to generate costrating data for each provider.

In one implementation, the distance of the risk-adjusted costs from theaverage costs is calculated, and a z-score and p-value to adjust forvolume differences amongst physicians are statistically calculated.Weighted standard deviation calculations are used to keepwithin-physician variances constant while adjusting for differences involume and variations across physicians. P-values may then be convertedto a 0-100 scale and presented as a star, gauge or other cost rating.

FIG. 1C is a diagram of an exemplary system for providing a consumerhealthcare guide, such as a web-based provider lookup tool, that may beimplemented to enable consumer access to provider quality and/or costrating data generated by the methods described above with reference toFIGS. 1A and 1B. The exemplary system includes a processor 101 and datastorage 102. The processor 101 is configured to receive search criteria,and retrieve one or more health-related listings based on the searchcriteria, in which the health-related listing includes associatedprovider quality rating data and/or cost rating data. Data storage 102is configured for storing health-related data and is communicativelycoupled to the processor 101 to enable the processor to retrievehealth-related data. Health-related data may include providerinformation listings (including physicians, hospitals and otherproviders) and associated provider quality rating data and provider costrating data retrieved from data storage 102. A graphical user interfaceor other user interface 103 may be provided that is communicatively withprocessor 101 and/or storage 102 for facilitating user access to thehealth-related data.

FIG. 1D is a flowchart of a method 100 for providing a consumerhealthcare guide, such as that illustrated in FIG. 1C. Method 100includes receiving 110 search criteria, and retrieving 120 one or morehealth-related listings based on the search criteria. Search criteriamay be entered by a consumer, such as a member of an insurance plan, andmay include search data such as the name or type (specialty) of providersought and a geographical area of search.

Search criteria may be entered by a user, wherein the user selects, forexample, a specific geographical location and specific type of provideror service desired. In this example, the user may select to view dataconcerning all healthcare providers in the selected area that providethe desired service or procedure.

In response to a search request entered by the user such as describedabove, the processor 101 generates a graphic user interface to display aconsumer healthcare guide including provider rating data. Providers mayinclude doctors and other providers of health-related services, as wellas facilities including hospitals, clinics and other facilities at whichhealth-related services are provided. The provider rating data mayinclude relative rating information concerning the cost and/or qualityfor each provider. Other data also may be displayed as desired by theimplementers of the system and/or the user.

Cost and quality rating data associated with a consumer healthcare guidemay be displayed, for example, as a discrete cost rating and qualityrating for each provider meeting the search criteria input by the user.For example, a cost rating may be a “$” rating, e.g., one $ as thelowest rating and three $$$ as the highest rating, and a quality ratingmay be a star rating “

”, e.g., one star

 as the lowest rating and three stars

 as the highest rating. Alternatively, a graphic image, such as a gaugesimilar to a temperature gauge that indicates the relative ratings ofproviders, may be displayed. Cost rating information may also includerelative cost, e.g., a cost percentage difference from the marketplace,and/or average costs. In addition, a consumer reviewing quality and costdata related to health-related data may also review the underlyingmeasures driving quality and cost ratings. For the consumer healthcareguide, quality and cost data may be provided about health-relatedservices and providers for a number of inpatient and outpatientprocedures and/or medical conditions. However, it should be understoodthat cost and quality information may be represented or displayed in anyway, and that the performance categories, “$” rating, star rating, andgauge rating display are exemplary implementations of communicatingrelative provider cost and quality ratings displayed via a consumerguide. Furthermore, additional data relevant to a consumer's healthcarechoice may be presented to a user in addition to or as an alternative tocost and quality data.

The guide may further display provider volume data, including suchinformation as the number of procedures (overall and/or specificprocedures) performed by each provider, patient age ranges, patientgender information (such as number or percentage of male and femalepatients), and/or top conditions treated or procedures performed by eachprovider, also may be displayed by the guide. The displayed number ofprocedures for each provider may be generated by counting the number ofeach type of procedure or medical episode attributed to each provider.Patient age range information and gender information may be determinedbased upon the patient age or gender information included in the claimdata associated with each procedure or episode attributed to eachprovider. The top condition(s) information may be determined by countingthe number of various procedures or services provided or conditionstreated by the provider and identifying one or more most commonlyperformed procedures or services, or conditions treated, by eachprovider. In one example, this provider volume data may assist guideusers to search for and identify providers that routinely treat aparticular condition or perform a procedure or service of interest. Theinformation further may enable guide users to search for and identifyproviders that routinely treat patients in their age and/or gendercategory.

FIGS. 2-16 depict exemplary displays associated with a web-basedprovider lookup tool that enables user access to physician and hospitalquality and cost ratings as well as other information that may berelevant to the user in selecting a physician. FIGS. 2-6 depict displaysof aggregate physician rating data (relating to all episodes assigned toeach physician), while FIGS. 7-10 depict displays of physician ratingdata associated with a selected condition or disease (diabetes in thisinstance). FIGS. 11-12 display sanction information relating to aselected physician. FIGS. 13-16 depict displays relating to hospitalquality and cost rating data.

FIG. 2 depicts a user interface displaying the results of an initialsearch for providers in a selected geographical location. The listingsare sorted by physician quality.

FIG. 3 depicts a user interface in which a number of physicians, forexample, selected from the list provided in FIG. 2, can be compared fortheir overall performance based upon all conditions they treat. Theinformation provided includes information about each provider (name,address, specialty, gender, birth date, years of practice, education,languages, and sanctions); provider rating data, including a rating ofseverity of patients treated, average cost of care, and quality of care;the age of patients treated by range and percentage; and a legend toassist the user in interpreting the provider rating data.

FIG. 4 depicts a display of additional details underlying the providerrating data displayed for a selected provider in FIG. 3. Provider ratingdetails include the number of patients, severity of patients treated,average cost of care, and quality of care as compared to state averagevalues. The provider's quality of care details includes the provider'scompliance with standard guidelines, number of patient hospital days peryear, number of patient emergency room visits per year, and number ofpatients with excess services (unnecessary services) as compared toaverage state values.

FIG. 5 depicts a display of the top conditions treated by a selectedprovider, including rating data on the number of patients, quality ofcare and cost of care for each condition.

FIG. 6 depicts a display of the top conditions treated by a providerwithin a specific category of conditions, including rating data on thenumber of patients, quality of care and cost of care for each condition.

FIG. 7 depicts a user interface that enables a user to perform anadvanced search for providers wherein a category or condition may bespecified. In one implementation, patient age range preferences and/orgender percentage treatment preferences may optionally be entered assearch criteria.

FIG. 8 depicts a display of the search results requested using theinterface of FIG. 7, wherein the condition specified is Diabetes and thephysicians are listed by quality rating.

FIG. 9 depicts a display of comparisons of physicians selected from thelist displayed in FIG. 8 for the specific condition (e.g. diabetes). Theinformation provided includes information about each provider (name,address, specialty, gender, birth date, years of practice, education,languages, and sanctions); provider rating data, including a rating ofseverity of patients treated, average cost of care, and quality of care;the age of patients treated by range and percentage; and a legend toassist the user in interpreting the provider rating data.

FIG. 10 depicts a display of additional details underlying the providerrating data displayed for a selected provider in FIG. 9. Provider ratingdetails include the number of patients, severity of patients treated,average cost of care, and quality of care as compared to state averagevalues for the selected condition (diabetes). The provider's quality ofcare details includes the provider's compliance with standardguidelines, number of patient hospital days per year, number of patientemergency room visits per year, and number of patients with excessservices (unnecessary services) as compared to average state values forthe selected condition.

FIGS. 11 and 12 depict optional displays that may be generated by theconsumer guide in which sanction information is displayed relating to aselected physician. An optional list of sanctions is provided in FIG.11, and optional details of a particular sanction selected from the listin FIG. 11 are provided in FIG. 12.

FIG. 13 depicts a display a user interface displaying the results of aninitial search for hospitals in a selected geographical location. Thelistings may be sorted by hospital quality. An “Add to Compare”function, accessed by clicking this option next to one or more of thelisted hospitals, adds the selected hospital to a group of hospitals forwhich a user can make a side-by-side comparison regarding a selectedmedical condition. FIG. 14 depicts an exemplary side-by-side comparisonof four hospitals.

FIG. 15 depicts an exemplary display of hospital rating data associatedwith a plurality of conditions treated by the hospital.

FIG. 16 depicts exemplary hospital summary rating information for aselected condition, such as a heart bypass.

The method and system according to the present invention may beimplemented using various combinations of software and hardware as wouldbe apparent to those of skill in the art and as desired by the user. Thepresent invention may be implemented in conjunction with a generalpurpose or dedicated computer system having a processor and memorycomponents.

From the above description and drawings, it will be understood by thoseof ordinary skill in the art that the particular implementations shownand described are for purposes of illustration only and are not intendedto limit the scope of the present invention. Those of ordinary skill inthe art will recognize that the present invention may be embodied inother specific forms without departing from its spirit or essentialcharacteristics. References to details of particular implementations arenot intended to limit the scope of the invention.

1. A computer-implemented method for generating healthcare providerquality rating data, comprising: providing data storage for storingmedical claim data; providing at least one computer processor programmedfor receiving a plurality of claim records representing servicesprovided by a plurality of healthcare providers to one or more patients;grouping the claim records into at least one claim group, each claimgroup including claim records representing care provided by one or moreproviders to a patient; assigning each claim group to a responsibleprovider; assessing the claim records in each claim group using expectedtreatment guidelines for the particular disease or condition associatedwith the claim group and generating a compliance score for the claimgroup, wherein the compliance score indicates the extent to which theclaim records in the claim group match the guidelines; aggregating thecompliance score for each claim group assigned to each provider togenerate a raw aggregate compliance score for each provider; normalizingthe provider's raw aggregate compliance score to a defined scale togenerate a normalized aggregate compliance score for each provider; andgenerating provider quality rating data for each provider using thenormalized aggregate compliance score.
 2. The method of claim 1, whereinthe claim groups are groups of facility claims, pharmacy claims,laboratory claims, and physician claims.
 3. The method of claim 1,wherein the claim groups are groups of facility claims representinginpatient care provided by a hospital to a patient.
 4. The method ofclaim 1, wherein the guidelines are evidence based medicine guidelines.5. The method of claim 1, wherein the aggregate raw compliance score,the normalized aggregate compliance score, and the provider qualityrating data are calculated separately for each condition or diseasetreated by each provider.
 6. The method of claim 1, wherein theaggregate raw compliance score, the normalized aggregate compliancescore, and the provider quality rating data are calculated to includeall conditions and diseases treated by each provider.
 7. The method ofclaim 1, wherein the defined scale used to generate the normalizedaggregate compliance score is a scale of 0 to
 100. 8. The method ofclaim 1, wherein the raw aggregate compliance score is normalized usingaverage aggregate compliance values for a defined provider specialty andgeographical region in which the provider is located.
 9. The method ofclaim 1, wherein the provider quality rating data comprises one or moreperformance categories that identify each provider's quality oftreatment in comparison to an average value.
 10. The method of claim 1,wherein the provider quality rating data comprises one or moreperformance categories that indicate each provider's quality oftreatment in comparison to others of the plurality of providers.
 11. Themethod of claim 1, wherein the provider quality rating data comprisesone or more stars or other graphic symbols that identify each provider'squality of treatment in comparison to an average value.
 12. The methodof claim 1, wherein the raw aggregate compliance score for each provideris a weighted sum of the aggregate compliance score of all claim groupsassigned to the provider and at least one additional utilization measureattributable to the provider.
 13. The method of claim 12, wherein theraw aggregate compliance score is a weighted sum of the aggregatecompliance score of all claim groups assigned to the provider and aplurality of utilization measures, the plurality of utilization measurescomprising a number of inpatient days per year, a number of emergencyroom visits per year, and a number of outlier procedures per year. 14.The method of claim 12, wherein the raw aggregate compliance score is aweighted sum of the aggregate compliance score of all claim groupsassigned to the provider and a plurality of utilization measures, theplurality of utilization measures comprising a death rate value, acomplication rate value, a length of stay value, and a number ofavoidable days per year.
 15. The method of claim 1, further comprisinggenerating provider volume data.
 16. A computer-implemented method forgenerating healthcare provider quality rating data, comprising:providing a data storage for storing medical claim data; providing atleast one computer processor programmed for receiving a plurality ofclaim records representing services provided by a plurality ofhealthcare providers to one or more patients; grouping the claim recordsinto at least one episode of care, wherein each episode of carecomprises claim records that relate to treatment of a patient by aprovider for a particular disease or condition; assigning each episodeof care to a responsible provider; assessing the claim records in eachepisode of care using expected treatment guidelines for the particulardisease or condition associated with the episode of care and generatinga compliance score for the episode of care, wherein the compliance scoreindicates the extent to which the claim records in the episode of carematch the guidelines; aggregating the compliance score for each episodeof care assigned to each provider to generate a raw aggregate compliancescore for each provider; normalizing the provider's raw aggregatecompliance score to a defined scale to generate a normalized aggregatecompliance score for each provider; and generating provider qualityrating data for each provider using the normalized aggregate compliancescore.
 17. A computer-implemented method for generating healthcareprovider cost rating data, comprising: providing a data storage forstoring medical claim data; providing at least one computer processorprogrammed for receiving a plurality of claim records representingservices provided by a plurality of healthcare providers to one or morepatients; grouping the claim records into at least one claim group, eachclaim group including claim records representing care provided by one ormore providers to a patient; assigning each claim group to a responsibleprovider; calculating the total cost of each claim group, wherein thetotal cost of a claim group is the sum of the costs associated with eachclaim record in the claim group; aggregating the total cost for eachclaim group to obtain a raw aggregate cost score for each provider;comparing the total aggregate cost of each claim group of care assignedto each provider to an expected cost value; normalizing the provider'sraw aggregate cost score to a defined scale to generate a normalizedaggregate cost score for the provider; and generating provider costrating data using the normalized aggregate cost score.
 18. The method ofclaim 17, wherein the claim groups are groups of facility claims,pharmacy claims, laboratory claims, and physician claims.
 19. The methodof claim 17, wherein the claim groups are groups of facility claimsrepresenting inpatient care provided by a hospital to a patient.
 20. Themethod of claim 17, wherein the expected cost value for a claim group isan average risk-adjusted cost value calculated from historical costdata.
 21. The method of claim 17, wherein the aggregate raw cost score,the normalized aggregate cost score, and the provider cost rating dataare calculated separately for each condition or disease treated by theprovider.
 22. The method of claim 17, wherein the aggregate raw costscore, the normalized aggregate cost score, and the provider cost ratingdata are calculated to include all conditions and diseases treated bythe provider.
 23. The method of claim 17, wherein the provider costrating data comprises one or more performance categories that indicatethe provider's cost of treatment in comparison to an average value. 24.The method of claim 17, further comprising generating provider volumedata.
 25. A computer-implemented method for generating healthcareprovider cost rating data, comprising: providing a data storage forstoring medical claim data; providing at least one computer processorprogrammed for receiving a plurality of claim records representingservices provided by a plurality of healthcare providers to one or morepatients; grouping the claim records into at least one episode of care,wherein each episode of care comprises claim records that relate totreatment of a patient by a provider for a particular disease orcondition; assigning each episode of care to a responsible provider;calculating the total cost of each episode of care, wherein the totalcost of an episode of care is the sum of the costs associated with eachclaim record in the episode of care; aggregating the total cost for eachepisode of care to obtain a raw aggregate cost score for each provider;comparing the total aggregate cost of each episode of care assigned toeach provider to an expected cost value; normalizing the provider's rawaggregate cost score to a defined scale to generate a normalizedaggregate cost score for the provider; and generating provider costrating data using the normalized aggregate cost score.